Case Report Successful Conservative Management of a ...

Case ReportSuccessful Conservative Management of a Dislocated IUD

Hasan Ali Inal,1 Zeynep Ozturk Inal,1 and Ender Alkan2

1Department of Gynaecology and Obstetrics, Konya Research and Training Hospital, Meram, 04220 Konya, Turkey2Department of Radiology, Konya Research and Training Hospital, Meram, 04220 Konya, Turkey

Correspondence should be addressed to Hasan Ali Inal; [email protected]

Received 27 November 2014; Revised 15 February 2015; Accepted 5 March 2015

Academic Editor: Vorapong Phupong

Copyright © 2015 Hasan Ali Inal et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Intrauterine contraceptive devices (IUDs) are widely utilized all over the world owing to their low cost and highefficacy. Uterine perforation is a rare complication that may occur at IUD insertion resulting in extrauterine location of theIUD. Traditionally, surgical removal of dislocated IUDs has been recommended. Case. A 68-year-old patient who had an IUD(Lippes loop) inserted 32 years ago and whose routine examination incidentally revealed a dislocated IUD in the abdominal cavity.The patient remained asymptomatic during three years of follow-up and the IUD was left in place. Conclusion. Asymptomaticpatients, whose vaginal examinations and ultrasonography or X-ray results reveal a dislocated IUD, may benefit from conservativemanagement.

1. Introduction

Intrauterine contraceptive devices (IUDs) are highly effec-tive, safe, convenient, and the most popular reversible birthcontrol method that are used by about 100 million womenall over the world [1]. In Turkey, it has been estimated that17% of women in the reproductive age use copper-releasingIUDs and levonorgestrel-releasing intrauterine systems thatare inserted by certified gynecologists,midwives, andmedicalpractitioners [2].

Problems associated with the use of IUD include infec-tion, uterine bleeding, pelvic abscess, and uterine perforation.The uterine perforation rate has been reported to be 1.6 per1,000 applications [3].This complication usually occurs at thetime of initial IUD insertion but the diagnosis is very oftendelayed.

The World Health Organization (WHO) suggested thatall dislocated IUDs have to be removed promptly due to therisk of bowel perforation [4]. Recently it has also been sug-gested that the dislocated IUD should be surgically removedin symptomatic patients while conservative management issuggested for asymptomatic patients [5]. While, in the past,a dislocated IUD was surgically removed via laparotomy,today, a dislocated IUD can usually be safely removed usinglaparoscopy [6].

We here report a patient with a dislocated IUD that wasfound in the abdominal cavity in whom surgical interventionwas not considered necessary.

2. The Case

A 68-year-old woman, gravida 4 and para 3 with one spon-taneous abortion and with no significant medical history,presented to the menopausal clinic for a routine check. Shehad a Lippes loop IUD inserted 32 years ago and she did nothave it checked for many years. Her previous gynecologicalexamination was performed 16 years ago. Standard vaginaland physical examinations revealed normal findings andall laboratory findings including a complete blood countand blood chemistry profile were within normal levels. TheIUD strings were not visible. The IUD was not detected byabdominal and pelvic transvaginal ultrasonography. There-fore, we suspected that the IUD might have dislocated.Abdominopelvic X-ray in anteroposterior position and com-puted tomography (CT) scan results revealed the dislocatedIUD in the right lower front part of the abdomen andno pathologies were found in the pelvic genital structures(Figures 1 and 2).

As the patient did not have any symptoms, we did notperform any surgical attempt (laparoscopy or laparotomy)

Hindawi Publishing CorporationCase Reports in Obstetrics and GynecologyVolume 2015, Article ID 130528, 3 pageshttp://dx.doi.org/10.1155/2015/130528

2 Case Reports in Obstetrics and Gynecology

Figure 1: Pelvic X-ray reveals a Lippes loop IUD in the pelvis.

Figure 2: CT scan shows the intrauterine device in the right upperfront part of the abdomen.

to remove the dislocated IUD. We observed the patient forthree years during which no signs nor symptoms related tothe dislocated IUD were observed.

3. Discussion

The risk of uterine perforation related to IUD insertion variesbetween 0.60 and 0.87 per 1,000 insertions depending on thetiming of the insertion, the skill of the performing physician,the position of the uterus (anteverted or retroverted), or thepresence of a uterine anomaly [7]. Uterine perforation occursmost frequently at the time of insertion [4]. Studies haveshown that more than 90% of uterine perforations occurwhen an IUD is inserted within the first postpartum yearduring the breast-feeding period [2, 8]. While a patient witha dislocated extrauterine IUD may be diagnosed at a healthcenter to which she has presented with symptoms of lowerabdominal pain, pregnancy, or irregular menstruation, IUD

dislocation can also be incidentally diagnosed during routinechecks without preceding symptoms or signs.

If dislocation of an IUD is suspected, vaginal examinationand transvaginal ultrasound can usually reveal that the IUDis not located in the uterine cavity. In order to exactlylocate the IUD, pelvic ultrasonography or abdominopelvicX-ray or, if those methods fail, advanced imaging methods(computerized tomography or magnetic resonance imaging)should be utilized [4, 7].

Phupong et al. [9] suggested that uterine perforationswere brought about by uterine contractions as a resultof infection and gave way to peritonitis and the authorsconsequently argued that a dislocated IUD could damageadjacent organs in the form of perforation of bowel andbladder, causing intestinal obstruction and pelvic abscess.

The WHO IUD report as well as some studies recom-mends that a dislocated IUD should be removed because ofpotential problems with bowel injury, chronic pelvic pain,and infertility [4, 6, 10].The preferredmethod for the removalof a dislocated IUD is laparoscopy but laparotomy mayhave to be performed in some cases. Adoni and Chetritreported no negative conditions such as adhesion formationwhen they evaluated 11 patients with dislocated IUDs (4with Lippes loops, 7 with copper-bearing IUDs: 3 Multiload;4 Nova-T) [11]. The authors argued that copper-IUDs orlevonorgestrel-releasing IUSs caused less complications andit was not mandatory to remove them. Similarly, Markovitchet al. evaluated 3 patients with dislocated IUDs laparo-scopically and reported no adhesion formations [5]. Studieshave demonstrated that adhesions are formed right after theperforation around the dislocated IUD and limited to thatarea [9, 11]. It has also been argued that adhesion formationmight bemore generalized in the event of surgical procedureslike laparoscopy or laparotomy [12].

When reviewing the literature, it became apparent thata dislocated IUD did not always need to be removed in anasymptomatic patient, despite the WHO recommendation.Since our patient had been asymptomatic for a very long timeand,moreover, did not wish to undergo surgical intervention,her condition was regularly monitored for three years and noproblems were observed.

4. Conclusion

A dislocated IUD in an asymptomatic patient does not needto be surgically removed. Such a patient might benefit fromconservative management.

Consent

Written informed consent was obtained from the patient forpublication of this case report and accompanying images.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Case Reports in Obstetrics and Gynecology 3

References

[1] L. Speroff, R. H. Glass, and N. G. Kase, “The intrauterinedevice,” in Clinical Gynecologic Endocrinology and Infertility, C.Mitchell, Ed., pp. 777–789, Williams &Wilkins, Baltimore, Md,USA, 5th edition, 1994.

[2] E. Caliskan, N. Ozturk, B. O. Dilbaz, and S. Dilbaz, “Analysis ofrisk factors associated with uterine perforation by intrauterinedevices,” European Journal of Contraception and ReproductiveHealth Care, vol. 8, no. 3, pp. 150–155, 2003.

[3] J. Ashton and D. Coulter, “Uterine perforation on intrauter-ine device insertion: is the incidence higher than previouslyreported?” Contraception, vol. 67, no. 1, pp. 53–56, 2003.

[4] WHO,Mechanism of Action, Safety, and Efficacy of IntrauterineDevices, World Health Organization, Geneva, Switzerland, 1987.

[5] O. Markovitch, Z. Klein, Y. Gidoni, M. Holzinger, and Y. Beyth,“Extrauterinemislocated IUD: is surgical removalmandatory?”Contraception, vol. 66, no. 2, pp. 105–108, 2002.

[6] M. T. Ozgun, C. Batukan, I. S. Serin, B. Ozcelik, M. Basbug,and M. Dolanbay, “Surgical management of intra-abdominalmislocated intrauterine devices,” Contraception, vol. 75, no. 2,pp. 96–100, 2007.

[7] H. J. Tatum and E. B. Connel, “Intrauterine contraceptivedevices,” in Contraception Science and Practice, M. Filshieand J. Guillebaud, Eds., pp. 144–171, Butterworth-Heinemann,London, UK, 1st edition, 1989.

[8] K. Andersson, E. Ryde-Blomqvist, K. Lindell, V. Odlind, and I.Milsom, “Perforations with intrauterine devices: report from aSwedish survey,” Contraception, vol. 57, no. 4, pp. 251–255, 1998.

[9] V. Phupong, T. Sueblinvong, K. Pruksananonda, S. Taneep-anichskul, and S. Triratanachat, “Uterine perforation withLippes loop intrauterine device-associated actinomycosis. Acase report and review of the literature,” Contraception, vol. 61,no. 5, pp. 347–350, 2000.

[10] R. S. Gill, D. Mok, M. Hudson, X. Shi, D. W. Birch, and S. Kar-mali, “Laparoscopic removal of an intra-abdominal intrauterinedevice: case and systematic review,” Contraception, vol. 85, no.1, pp. 15–18, 2012.

[11] A. Adoni and A. B. Chetrit, “The management of intrauterinedevices following uterine perforation,” Contraception, vol. 43,no. 1, pp. 77–81, 1991.

[12] J. M. Roberts andW. J. Ledger, “Operative removal of intraperi-toneal intrauterine contraceptive devices—a reappraisal,” TheAmerican Journal of Obstetrics and Gynecology, vol. 112, no. 6,pp. 863–865, 1972.

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